Nausea and vomiting

Last updated: March 9, 2022

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Nausea refers to an unpleasant sensation that is often localized to the abdomen and typically interpreted as an urge to vomit. Vomiting is the forceful oral expulsion of gastric contents. Although nausea and vomiting are the major symptoms of many gastrointestinal disorders, diseases of other organ systems should be considered during the workup. Nausea and vomiting can be due to early pregnancy, an adverse effect of medications or toxic ingestion, or a host of pathologies in other organ systems such as the CNS, endocrine, and vestibular systems. Nausea and vomiting may also be the manifesting symptoms of a functional disorder. Patients presenting with acute onset of recurrent vomiting should be evaluated for signs of dehydration and electrolyte and acid-base disorders, which should be corrected at the earliest opportunity. A thorough history and physical examination should be performed to narrow down the differential diagnoses and guide further diagnostic workup and treatment. Accompanying symptoms (e.g., fever, abdominal pain, headache) may provide clues as to the underlying disorder. Nausea and vomiting in children are not addressed here.

Evaluate and stabilize life-threatening complications before identifying and treating underlying causes of nausea and vomiting. The highest yield step to determine etiology is a thorough clinical evaluation.

Initial management [1][2][3]

Further management

Many herbal supplements can result in poisoning or cause herb-drug interactions that lead to nausea and vomiting (e.g., St John's Wort may cause serotonin syndrome); ask all patients specifically whether they use any herbal supplements. [4][5]

Consider whether antiemetics are necessary: Nausea may be self-limiting, and adverse effects of antiemetics include extrapyramidal symptoms due to metoclopramide and QT prolongation due to ondansetron. [1]

Red flags for nausea and vomiting

The following are red flags for life-threatening causes of nausea and vomiting.

Immediately life-threatening causes

Life-threatening diagnoses (e.g., meningitis, appendicitis, sepsis) can mimic self-limiting gastroenteritis. Avoid anchoring bias to prevent misdiagnosis and treatment delay.

Common complications of vomiting [1]

Disposition [1]

  • Consider hospital admission in patients with any of the following:
    • Severe vomiting refractory to antiemetic therapy
    • Unremitting pain
    • Significant metabolic abnormalities
    • Evidence of an acute underlying condition or surgical pathology that requires in-hospital evaluation and treatment
    • Insufficient response to IV fluids
    • Inability to adhere to discharge instructions or attend outpatient follow-up
  • Consider discharge home if all of the following criteria are fulfilled:
    • There are no life-threatening causes identified or other criteria for admission.
    • The patient appears well, can tolerate oral clear liquids, and can adhere to discharge instructions.
    • Outpatient follow-up is ensured.

Not all patients require IV hydration; oral rehydration therapy is effective and can be considered in patients without shock, refractory vomiting, or serious underlying pathology to reduce costs, admission rates, and complications. [10]

There is no standard panel of tests to determine the etiology of nausea and vomiting because of the broad differential diagnosis. Choose diagnostic testing based on clinical suspicion.

Laboratory studies

Routine [2][3]

In patients with severe and sustained vomiting

Further diagnostic studies [2][3]

Diagnostic testing based on suspected system involvement
Laboratory studies Imaging and other interventions
HEENT
  • N/A
Cardiopulmonary

Abdominal/pelvic

Neurological/psychiatric
Endocrine/metabolic
  • N/A

In patients with suspected gastroenteritis without signs of sepsis, it may not be necessary to do any diagnostic testing.

Rome IV diagnostic criteria for functional nausea and vomiting disorders [12][13]

Diagnosis of a functional nausea and vomiting syndrome requires symptom onset at least six months prior, with symptoms present for the previous three months.

  • Chronic nausea and vomiting syndrome (CNVS)
    • Nausea at least once a week and/or one or more instances of vomiting per week
    • Exclusion of self-induced vomiting, eating disorders, regurgitation, or rumination syndrome
    • Routine investigations are negative for organic, systemic, or metabolic diseases that could explain the symptoms.
  • Cyclic vomiting syndrome (CVS)
    • Acute episodes of vomiting, lasting less than one week
    • A minimum of three episodes of vomiting in the prior year and two episodes in the past six months, with at least one symptom-free week in between the most recent episodes
    • No vomiting outside of acute episodes (other milder symptoms may be present)
  • Cannabinoid hyperemesis syndrome (CHS)
    • Onset, duration, and frequency of episodes similar to CVS
    • Associated with chronic cannabis use
    • Sustained cessation of cannabis use resolves vomiting
Clinical features Diagnostic findings Acute management
Acute coronary syndrome [14][15]
Acute pancreatitis [16][17][18]
  • Severe epigastric pain that radiates to the back
  • Nausea, vomiting
  • Epigastric tenderness, guarding, rigidity
  • Upper abdominal pain
  • Hypoactive bowel sounds
  • History of gallstones or alcohol use
Mechanical bowel obstruction [19][20][21][22]
  • Colicky abdominal pain
  • Obstipation/bloating
  • Progressive nausea and vomiting (late finding)
  • Diffuse abdominal distention, tympanic abdomen, collapsed rectum on DRE
  • Tinkling bowel sounds
  • History of abdominal surgery
  • X-ray abdomen
  • CT abdomen with IV contrast
    • Similar findings as on x-ray
    • Transition point at site of obstruction
DKA [23][24]
Meningitis [25][26][27]
Hyperemesis gravidarum [2][28][29][30]
  • Ketonuria
  • Electrolyte and acid-base abnormalities
Clinical features Diagnostic findings Acute management
Postoperative nausea and vomiting (PONV) [31][32]
  • Nausea and/or vomiting within the first 24–48 hours of surgery

Chemotherapy-induced nausea and vomiting (CINV) [33][33][34][35][36][37]

  • See “Treatment of CINV.”

Uncomplicated first-trimester nausea and vomiting [2][28][29][30][38]

Infectious gastroenteritis [39][40][41][42][43]

Migraine [44]

Gastritis [47][48]

Gastroparesis [49]

Vestibular causes [51]

Nausea and vomiting are common adverse effects of numerous medications. When this occurs, use suitable alternatives or start with a lower dose to minimize symptoms.

Infectious causes

Noninfectious causes

  1. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  2. Quigley EMM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001; 120 (1): p.263-286. doi: 10.1053/gast.2001.20516 . | Open in Read by QxMD
  3. Anderson W, Strayer S,. Evaluation of Nausea and Vomiting in Adults: A Case-Based Approach. Am Fam Physician. 2013 .
  4. Jatau AI, Aung MM, Kamauzaman TH, Chedi BA, Sha'aban A, Rahman AF. Use and toxicity of complementary and alternative medicines among patients visiting emergency department: systematic review.. J Intercult Ethnopharmacol.. 2016; 5 (2): p.191. doi: 10.5455/jice.20160223105521 . | Open in Read by QxMD
  5. Parker V, Wong AH, Boon HS, Seeman MV. Adverse Reactions to St John's Wort. Can J Psychiatry. 2001; 46 (1): p.77-79. doi: 10.1177/070674370104600112 . | Open in Read by QxMD
  6. Scorza K, Williams A, Phillips JD, Shaw J. Evaluation of nausea and vomiting.. Am Fam Physician. 2007; 76 (1): p.76-84.
  7. Majumdar I, Black TA, Nair J. Hypernatremia Management: Focus on Etiology. Clin Pediatr (Phila). 2017; 57 (1): p.96-98. doi: 10.1177/0009922816685819 . | Open in Read by QxMD
  8. Canziani BC, Uestuener P, Fossali EF, et al. Clinical Practice: Nausea and vomiting in acute gastroenteritis: physiopathology and management. Eur J Pediatr. 2017; 177 (1): p.1-5. doi: 10.1007/s00431-017-3006-9 . | Open in Read by QxMD
  9. Woodruff WW, Merten DF, Kirks DR. Pneumomediastinum: an unusual complication of acute gastrointestinal disease. Pediatr Radiol. 1985; 15 (3): p.196-198. doi: 10.1007/bf02388612 . | Open in Read by QxMD
  10. Fonseca BK, Holdgate A, Craig JC. Enteral vs Intravenous Rehydration Therapy for Children With Gastroenteritis. Arch Pediatr Adolesc Med. 2004; 158 (5): p.483. doi: 10.1001/archpedi.158.5.483 . | Open in Read by QxMD
  11. Galgano SJ, McNamara MM, Peterson CM, Kim DH, Fowler KJ, Camacho MA, Cash BD, Chang KJ, Feig BW, Gage KL, Garcia EM, Kambadakone AR, Levy AD, Liu PS, Marin D, Moreno C, Pietryga JA, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Left Lower Quadrant Pain-Suspected Diverticulitis. J Am Coll Radiol.. 2019; 16 (5): p.S141-S149. doi: 10.1016/j.jacr.2019.02.015 . | Open in Read by QxMD
  12. Aziz I, Palsson OS, Whitehead WE, Sperber AD, Simrén M, Törnblom H. Epidemiology, Clinical Characteristics, and Associations for Rome IV Functional Nausea and Vomiting Disorders in Adults. Clin. Gastroenterol. Hepatol.. 2019; 17 (5): p.878-886. doi: 10.1016/j.cgh.2018.05.020 . | Open in Read by QxMD
  13. Rome IV Diagnostic Criteria for Functional Gastrointestinal Disorders. https://theromefoundation.org/rome-iv/rome-iv-criteria/. Updated: January 16, 2016. Accessed: January 28, 2022.
  14. Gan TJ, Diemunsch P, Habib AS, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014; 118 (1): p.85-113. doi: 10.1213/ANE.0000000000000002 . | Open in Read by QxMD
  15. Pierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2013; 13 (1): p.28-32. doi: 10.1093/bjaceaccp/mks046 . | Open in Read by QxMD
  16. NCCN clinical Practice Guidelines in Oncology: Antiemesis, Version 1.2019. https://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Updated: February 28, 2019. Accessed: September 16, 2019.
  17. Brafford MV, Glode A. Olanzapine: an antiemetic option for chemotherapy-induced nausea and vomiting.. Journal of the advanced practitioner in oncology. 2014; 5 (1): p.24-9.
  18. Rapoport BL. Delayed Chemotherapy-Induced Nausea and Vomiting: Pathogenesis, Incidence, and Current Management. Frontiers in Pharmacology. 2017; 08 . doi: 10.3389/fphar.2017.00019 . | Open in Read by QxMD
  19. Rao KV, Faso A. Chemotherapy-induced nausea and vomiting: optimizing prevention and management. Am Health Drug Benefits. 2012; 5 (4): p.232-40.
  20. Hawkins R, Grunberg S. Chemotherapy-Induced Nausea and Vomiting: Challenges and Opportunities for Improved Patient Outcomes. Clin J Oncol Nurs. 2009; 13 (1): p.54-64. doi: 10.1188/09.cjon.54-64 . | Open in Read by QxMD
  21. Wegrzyniak LJ, Repke JT, Ural SH. Treatment of hyperemesis gravidarum.. Reviews in obstetrics & gynecology. 2012; 5 (2): p.78-84.
  22. Committee on Practice Bulletins-Obstetrics.. ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy.. Obstet Gynecol. 2018; 131 (1): p.e15-e30. doi: 10.1097/AOG.0000000000002456 . | Open in Read by QxMD
  23. Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003; 68 (1): p.121-128.
  24. Herell EH. Nausea and Vomiting of Pregnancy. Am Fam Physician.. undefined .
  25. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017; 65 (12): p.e45-e80. doi: 10.1093/cid/cix669 . | Open in Read by QxMD
  26. Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics. Clin Microbiol Infect. 2015; 21 (8): p.744-749. doi: 10.1016/j.cmi.2015.03.002 . | Open in Read by QxMD
  27. Barr W, Smith A. Acute Diarrhea in Adults. Am Fam Physician. 2014 .
  28. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018; 66 (7): p.e1-e48. doi: 10.1093/cid/cix1085 . | Open in Read by QxMD
  29. Switaj T, Winter K, Christensen S. Diagnosis and Management of Foodborne Illness. Am Fam Physician. undefined .
  30. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38 (1): p.1-211. doi: 10.1177/0333102417738202 . | Open in Read by QxMD
  31. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55 (6): p.754-762. doi: 10.1212/wnl.55.6.754 . | Open in Read by QxMD
  32. Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Therapeutic Advances in Neurological Disorders. 2013; 6 (6): p.369-374. doi: 10.1177/1756285613489765 . | Open in Read by QxMD
  33. Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol. 2017; 112 (7): p.988-1013. doi: 10.1038/ajg.2017.154 . | Open in Read by QxMD
  34. Rugge M, Sugano K, Sacchi D, Sbaraglia M, Malfertheiner P. Gastritis: An Update in 2020. Curr Treat Options Gastroenterol. 2020; 18 (3): p.488-503. doi: 10.1007/s11938-020-00298-8 . | Open in Read by QxMD
  35. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical Guideline: Management of Gastroparesis. Am J Gastroenterol. 2013; 108 (1): p.18-37. doi: 10.1038/ajg.2012.373 . | Open in Read by QxMD
  36. Abell TL, Camilleri M, Donohoe K, et al. Consensus Recommendations for Gastric Emptying Scintigraphy: A Joint Report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Am J Gastroenterol. 2008; 103 (3): p.753-763. doi: 10.1111/j.1572-0241.2007.01636.x . | Open in Read by QxMD
  37. Flake Z, Linn B, Hornecker J. Practical Selection of Antiemetics in the Ambulatory Setting. Am Fam Physician. 2015 .
  38. O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013; 127 (4). doi: 10.1161/cir.0b013e3182742cf6 . | Open in Read by QxMD
  39. E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014 . doi: 10.1016/j.jacc.2014.09.017 . | Open in Read by QxMD
  40. Crockett et al. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018; 154 (4): p.1096-1101. doi: 10.1053/j.gastro.2018.01.032 . | Open in Read by QxMD
  41. D Jeffrey. Acute Pancreatitis. AAFP. 2014 .
  42. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology. 2018; 154 (4): p.1103-1139. doi: 10.1053/j.gastro.2018.01.031 . | Open in Read by QxMD
  43. American College of Radiology ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. https://acsearch.acr.org/docs/69467/Narrative/. Updated: January 1, 2018. Accessed: March 30, 2018.
  44. American College of Radiology ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. https://acsearch.acr.org/docs/69476/Narrative/. Updated: January 1, 2013. Accessed: June 3, 2019.
  45. Jackson PG, Raiji MT. Evaluation and Management of Intestinal Obstruction. American Family Physician. 2011; 83 (2): p.159-165.
  46. Griffiths S, Glancy DG. Intestinal obstruction. Surgery. undefined; 35 (3): p.3. doi: 10.1016/j.mpsur.2016.12.005 . | Open in Read by QxMD
  47. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32 (7): p.1335-1343. doi: 10.2337/dc09-9032 . | Open in Read by QxMD
  48. Westerberg D. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician. 2013 .
  49. Bamberger DM. Diagnosis, initial management, and prevention of meningitis.. Am Fam Physician. 2010; 82 (12): p.1491-8.
  50. Seehusen DA, Reeves MM, Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003; 68 (6): p.1103-1108.
  51. Mount HR, Boyle SD. Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention.. Am Fam Physician. 2017; 96 (5): p.314-322.
  52. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol. 2016; 27 (suppl_5): p.v119-v133. doi: 10.1093/annonc/mdw270 . | Open in Read by QxMD
  53. Navari RM. Treatment of Breakthrough and Refractory Chemotherapy-Induced Nausea and Vomiting. BioMed Research International. 2014; 2015 : p.1-6. doi: 10.1155/2015/595894 . | Open in Read by QxMD
  54. Kamen C, Tejani MA, Chandwani K, et al. Anticipatory nausea and vomiting due to chemotherapy. Eur J Pharmacol. 2014; 722 : p.172-179. doi: 10.1016/j.ejphar.2013.09.071 . | Open in Read by QxMD
  55. Einhorn LH, Grunberg SM, Rapoport B, Rittenberg C, Feyer P. Antiemetic therapy for multiple-day chemotherapy and additional topics consisting of rescue antiemetics and high-dose chemotherapy with stem cell transplant: review and consensus statement. Supportive Care in Cancer. 2010; 19 (S1): p.1-4. doi: 10.1007/s00520-010-0920-z . | Open in Read by QxMD
  56. Ryan JL. Treatment of Chemotherapy-Induced Nausea in Cancer Patients.. European oncology. 2010; 6 (2): p.14-16.
  57. Abell TL, Adams KA, Boles RG, et al. Cyclic vomiting syndrome in adults. Neurogastroenterology & Motility. 2008; 20 (4): p.269-284. doi: 10.1111/j.1365-2982.2008.01113.x . | Open in Read by QxMD
  58. Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol. 2016; 111 (5): p.602-622. doi: 10.1038/ajg.2016.126 . | Open in Read by QxMD
  59. Perwitasari DA, Gelderblom H, Atthobari J, et al. Anti-emetic drugs in oncology: pharmacology and individualization by pharmacogenetics. International Journal of Clinical Pharmacy. 2011; 33 (1): p.33-43. doi: 10.1007/s11096-010-9454-1 . | Open in Read by QxMD
  60. Tan L, Liu J, Liu X, et al. Clinical research of Olanzapine for prevention of chemotherapy-induced nausea and vomiting. Journal of Experimental & Clinical Cancer Research. 2009; 28 (1): p.131. doi: 10.1186/1756-9966-28-131 . | Open in Read by QxMD
  61. Sharkey KA, Wiley JW. The Role of the Endocannabinoid System in the Brain–Gut Axis. Gastroenterology. 2016; 151 (2): p.252-266. doi: 10.1053/j.gastro.2016.04.015 . | Open in Read by QxMD
  62. Darmani NA. Mechanisms of Broad-Spectrum Antiemetic Efficacy of Cannabinoids against Chemotherapy-Induced Acute and Delayed Vomiting. Pharmaceuticals. 2010; 3 (9): p.2930-2955. doi: 10.3390/ph3092930 . | Open in Read by QxMD
  63. James E. Tisdale. Drug-induced Diseases: Prevention, Detection, and Management. American society of health-system phramacists : p. 834

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